Ethics and the Medical Profession in the Indian Context

The following is a response that I wrote on my high school Whatsapp group in response to some heated debate about the Medical Profession and stories about their sub-standard ethics.  Blogging it for others.

All professions providing some form of service have a lot of regulations around ‘ethicality’ and ‘morality’. This applies to financial professionals – people who give investment advice to their clients as well as the medical profession. I have worked in the finance profession all my life and have now moved into a regulator role. And I am applying some of the principles that we adopt for the financial advisory profession in this discussion.

No one will grudge a super-specialty doctor charging high fees because he has spent years and money in acquiring his skill and he does deliver results! They have spent lakhs and crores on that costly private medical education or on equipment and therefore they must now recover their cost. It is called ‘Return on Investment’. Yes I get that! But this argument immediately throws the ‘Hippocratic Oath’ out of the window and brings the doctor down from the heights of being in a ‘noble profession’ to being just another businessman.

One of the tests of ethicality is ‘Conflict of Interest’.  In any doctor-patient relationship, whose side is the doctor on? Is the doctor looking out for the best interest of the patient or is he/she acting in self-interest?  This I where all the talk of the ‘cut’ business comes into play. If as a financial advisor, I get a cut for every mutual fund I recommend and get the customer to invest in, then there are no marks for guessing that my interest would be to recommend the mutual fund which gives me the highest commission rather than the one that is best for the customer.  I have immediately compromised the financial health of the customer. Translate this to the medical profession and you have a large number of stories of over-prescribing, over-testing, and even advising surgery when not warranted. There is both anecdotal evidence of this as well as established case law.  Just do a google search.

How often do doctors sit with a patient and their relatives and go through the case, discuss the pros and cons of various optional routes of treatment and explain the doctor’s reasoning for the line of treatment that is being recommended? If the medical profession is prepared to be called just another business then business ethics demands that they be transparent.  

In my google search I came across a book authored by Pune-based Dr Abhay Shukla and Dr Arun Gadre. It is an English translation of the Marathi one — Kaifiyat pramanik doctoranchi (reflections by sincere doctors). It contains interviews of 78 practicing doctors from Mumbai, Pune, Delhi, Kolkata, Bangalore and Chennai. “These whistleblower doctors have mustered the ethical courage to expose facts for the first time on such a scale,” Dr Arun Gadre says. Several doctors spoke up including Dr Vijay Ajgaonkar, senior diabetologist from Mumbai, who says, “Now our greed has increased to the extent that when a patient of one consultant goes to another consultant, the second one prescribes the same medicine, but merely changes the brand to show that he is doing something different. And it is true that this profession has now become completely commercial.” The book describes every unethical practice from the horse’s mouth: cuts or referral fees for diagnostics as well as medical procedures; ‘Study tours’, also known as foreign trips funded by big labs and pharma companies for doctors; hospitals employing people who will rush to an accident scene and act as social workers to get the injured to the hospital that employs them. Etc. Etc.

There is one bold argument that is commonly made- that C is for choice. Whenever I hear this I am reminded of the time when my late father died way back in 1994. My brothers and I were doing the rituals of the kriya karma and were in a grieving state . The ‘priest’ (who smelled money as my brother was working in the UK and I came from Japan) would recommend to us one ritual after another emphasizing how not doing it would bring some pain or harm to our dad’s soul. He would always end his dire warnings with the words “it is your choice” Similarly, when relatives are worried about the health of their loved one, the doctor is in a position of trust. And at that time if he/she is going to be conflicted and concerned about making a commission then how different is he/she from this unethical priest?  

Long story short, the medical profession surely needs some soul searching as to where it all went south.

And finally there are some good apples and some bad apples in every basket.  The problem is that the bad apples give the whole basket a bad name.

On Acquiring Canadian Citizenship

Today (11^th Sept-2015) marks the final step in a 10-year journey for my family, as we complete our quest for acquiring Canadian Citizenship- a process we started in Sep-2005

I write this with mixed feelings. When I woke up today I was an Indian citizen and by the time the sun sets today I will have become a Canadian Citizen having taken the oath of citizenship at a Citizenship ceremony in the Art Gallery of Alberta, Edmonton after which I will receive the certificate of citizenship

The citizenship ceremony involves affirming to be faithful and bear true allegiance to Her Majesty Queen Elizabeth the Second, Queen of Canada (the symbol of the government in Canada) and to faithfully observe the laws of Canada and fulfil my duties as a Canadian Citizen. (Note: The Queen personifies the state and is the personal symbol of allegiance, unity and authority for all Canadians). My wife, Anita and Rohan will be by my side as we together embrace a new identity as citizens of the first world. (Note:  My daughter, Ankita acquired Canadian Citizenship earlier this year).

Today will also commence a process of renouncing Indian Citizenship, surrendering our passport and (optionally) acquiring Overseas Citizen of India (OCI) status and documentation. India does not recognize dual citizenship, hence they have devised this OCI status which equates us with NRIs in terms of financial transactions, property ownership and visa-free entry into India.

From a legal standpoint, this milestone for us means that henceforth we will travel on a Canadian passport and be eligible to vote in Canadian elections while losing the right to vote in Indian elections. The Canadian passport is decidedly more respected and accepted as it enables visa-free or visa-on-arrival entry to over 177 countries. Other than that very little changes. Canada encourages landed immigrants to bring with them their cultural heritage and value systems from their land of birth and upbringing. Canadians are rightfully proud of the multiculturalism that is visible everywhere you look. So we will continue to be Indian at heart while also being Canadian in our outlook and worldview.

As the saying goes, you can take a person out of India but you cannot take India out of a person!

Let he who is without sin cast the first stone!

There is a biblical story that goes like this.  When an adulteress was brought to the village square and was about to be meted out the traditional punishment of death by stoning, all the villagers gathered and took up a stone each. When the family of the woman appealed to Jesus who was in the village, he apparently said words to the effect that: “This woman must be punished. But Let he who is without sin cast the first stone”.

I am reminded of this story when I read all the posts in various whatsapp groups about recent cases wherein famous Politicians and Actors in India are able to hire top-notch lawyers or pay their way out of tough criminal cases and avoid going to jail. The common refrain is that the law should be applicable to everyone and just because someone has money-power he/she should not be spared. I wonder how many of us have always strictly adhered to various laws?

We need to do some soul searching and ask ourselves how many times we have paid a bribe – to the traffic cop after jumping a red light; to the TTE for a berth when there were others ahead of us in the waitlist; to the government clerk or ‘karmchaari’ for speeding up our case; to the IT officer to be lenient etc. etc.

My point is about the principle not the magnitude of the crime or the amount of the bribe.  If we value our work to be done and don’t mind paying a 1000 Rupees to escape the law we too will probably pay up.  If our child was involved – even unwittingly- in a crime, would we actually tell the cops, “he is a criminal, take him and punish him/her to the full extent of the law”? No. My bet is that our first thought will be to spend whatever it takes to ensure our child goes scot free.   We will probably consider a few thousand bucks well spent if our kid can avoid a night in jail.  In Sallu’s case a few lakhs/crores is the same as a few thousand bucks is to us. The amount is relative. What is not relative and common is that we all are willing to pay something and escape facing the law.

I am sharing this thought for us to reflect and self-introspect.

Canada's Health Care System: A personal story

Feeling confident (though still slightly apprehensive) before surgery for a total thyroidectomy on Monday Jan 26. This post is not about the 'why' and 'what for?' about my surgery. This is aimed at being a feel good story about the care and human elements in the health care delivery process in Canada!

Two months ago when the biopsy results came in, the surgeon’s office called me. The surgeon spent a good 30-minutes explaining to me the results, what they meant, the likely paths (with probabilities) that the cysts on my thyroid might take and my treatment options. This was indeed an illustrative talk with him drawing out the diagrams on his iPad! Given the odds and the prognosis I took his advice to go for a total thyroidectomy in one go, and was lucky to get a date within two months. (Alberta’s, like most of Canada, public health system is totally free for residents but is notorious for longish wait times for elective non-life threatening conditions!). 

A week before the surgery, I was pleasantly surprised to receive a call from the hospital (https://www.covenanthealth.ca/…/misericordia-community-hosp…) inviting me to attend a pre-surgical assessment clinic. During the more than 2 hour session I was seen by three different nurses and an anaesthetist, to assess my readiness, offer counselling and answer any questions that I may have. I was ushered into a regular examination room offered a seat at the table and a glass of water/coffee etc. After the routine physical check-up the 2nd nurse took an ECG and then the third nurse walked me through the entire process right from preparation at home and diet restrictions from the night before surgery, through to what the admission process will look like, time expected in the operating room followed by time in the recovery room, before I would be taken back to my room for an overnight stay. She concluded with the discharge and post-operative care that will normally be required. She told me that precise instructions for my condition would be given at time of discharge. This was not just her talking and my taking notes furiously. She told me to put away my note-pad and instead wrote the pertinent details in a pre-printed prepared booklet for me to carry back and not worry about missing some detail. By the end of her talk, my expectations were set and most of my routine questions – e.g.: what to wear, what to (and not to) eat and what to do with my glasses etc., were taken care of. Despite all the details that she provided, she assured me that on the day of surgery, the surgeon himself will be ready and willing to answer any further questions that I may have. The one thing that stuck with me long after the meeting was her mentioning not to get worried when I hear the surgical team talking at the time of surgery and asking me or each other what might look like routine questions. She assured me that this was because they are required to follow the WHO recommended ‘Safe Surgery Check List’ to ensure the best and safest possible outcome from the surgery. Part of this is to encourage me – and members of my family - to ask as many questions as I have and to keep talking to the surgical team. The time in the operating room is estimated at 1-hr & 40 minutes.

I was next seen by the Anaesthetist who put me completely at ease explaining how the General Anaesthesia will be administered, how the attending anaesthetist will be constantly monitoring me and how they will slowly revive me from deep slumber and ensure my condition is stable before moving me to the recovery room where another set of nurses will take over. She told me that I will probably need to be in the recovery room for an estimated 1-hour after which I will be moved to my room where I will be under observation overnight before being discharged the next day. The pre-assessment clinic then ended with a visit to the pathology lab within the hospital itself for getting a detailed blood analysis report. (More paper for my already thick binder!).
Sharing the story in some detail, as it made me realize the true meaning of what being a resident of a first world country meant. The medical profession at all levels is totally committed not just to treating me (admit – do procedure- discharge) but treating me like a human being all through the process, recognizing that (my family and) I would have emotional worries and taking the pains to address our concerns. And all this for an ordinary person. I am no VIP!

I recognize that while free at a transactional level, this is truly my tax dollars at work. But I would gladly pay any amount of tax so long as I have the assurance that those tax dollars will work for me, if and when I, or my family, need it. 

Blessed to be living (and paying taxes) in Canada!